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592 REVIEW ARTICLE Physical Examination of the Knee: A Review of the Original Test Description and Scientific Validity of Common Orthopedic Tests Gerard A. Malanga, MD, Steven Andrus, MD, Scott F. Nadler, DO, James McLean, MD ABSTRACT. Malanga GA, Andrus S, Nadler SF, McLean J. tion on the sensitivity and specificity along with other infor- Physical examination of the knee: a review of the original test mation about the validity of these tests in clinical practice. To description and scientific validity of common orthopedic tests. standardize how physical examinations are performed and Arch Phys Med Rehabil 2003;84:592-603. compared, they should follow the original description or agreed-on standards. In addition, the significance of a physical Objectives: To present the original descriptions of common examination finding must be understood to ensure that patients orthopedic physical examination maneuvers of the knee and with knee complaints are accurately diagnosed and properly then to review the literature to support the scientific validity of treated. these tests. Key Words: Anterior cruciate ligament; Knee; Menisci, Data Sources: MEDLINE (1970–2000) searches were per- tibial; Physical examination; Posterior cruciate ligament; Re- formed, as were reviews of various musculoskeletal examina- habilitation. tion textbooks that describe physical examination maneuvers of © 2003 by the American Congress of Rehabilitation Medi- the knee. These references were then reviewed for additional cine and the American Academy of Physical Medicine and references and crossed back to the original description (when Rehabilitation possible) of these named tests. Study Selection: All articles that discussed the sensitivity USCULOSKELETAL PROBLEMS are among the most and specificity of the physical examination maneuvers were 1 extracted. This information was reviewed for accuracy and Mcommon reasons for patient visits to physicians. Unfor- tunately, it seems that most physicians are not adequately then summarized. 2-5 Data Extraction: Multiple MEDLINE and text searches trained in the evaluation of many musculoskeletal problems. were performed by using the terms of the test maneuver, the The knee is particularly susceptible to traumatic injury because joint tested, and the term physical examination. Any article of its vulnerable location midway between the hip and the with this information was reviewed until the article describing ankle, where it is exposed to the considerable forces transmit- the original description was found. Articles dating from that ted through the distal extremity from the ground. A thorough original article to the present were reviewed for information on examination of all knee structures should be a part of every the sensitivity and specificity of the test. knee evaluation. To ensure the most accurate diagnosis possi- Data Synthesis: Literature reviewing the sensitivity and ble, it is crucial that testing maneuvers be performed correctly specificity of the tests reviewed is summarized in text and table and that the examiner is aware of each maneuver’s sensitivity, form. The Lachman test seems to be very sensitive and specific specificity, and limitations. We reviewed the literature to find for the detection of anterior cruciate ligament tears. For pos- the original descriptions of commonly used physical examina- terior cruciate ligament tears, the posterior drawer test is also tion maneuvers of the knee and then searched the literature very sensitive and specific and is enhanced with other tests, again for studies that examined the sensitivity and specificity of such as the posterior sag sign. For meniscal tears, the McMur- these tests. ray test is very specific but has a very low sensitivity, whereas joint line tenderness has fairly good sensitivity but lacks good METHODS specificity. Although collateral ligament testing seems to be MEDLINE (1970–2000) searches were performed, as were sensitive and specific, there is a lack of well-designed studies reviews of various musculoskeletal examination textbooks. that scientifically validate the sensitivity and specificity of Key words used included knee, examination, anterior cruciate these tests. Common tests for patellofemoral pain and patellar ligament, posterior cruciate ligament, medial collateral liga- instability lack sensitivity when correlated with pathologic ment, lateral collateral ligament, patellofemoral pain, patellar operative findings. dislocation, McMurray test, Lachman test, anterior drawer Conclusions: Most physical examination tests could be ref- test, posterior drawer test, pivot shift test, apply grind test, erenced back to an original description, with variable informa- bounce home test, and grind test. The articles were obtained from local medical libraries and, when necessary, through interlibrary loan. The articles were then reviewed for additional references and searched back to the original description (when From the Kessler Institute for Rehabilitation, West Orange, NJ (Malanga, Andrus); possible) of the named tests. All articles that discussed the and Department of Physical Medicine and Rehabilitation, Univ of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, NJ (Malanga, Nadler, sensitivity and specificity of these tests were extracted. This McLean). information was reviewed for accuracy and then summarized. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any Tests for the Anterior Cruciate Ligament organization with which the authors are associated. Reprint requests to Gerard A. Malanga, MD, Spine, Sports and Occupational The anterior cruciate ligament (ACL) is among the main Rehabilitation, Kessler Institute for Rehabilitation, 1199 Pleasant Valley Way, West Orange, NJ 07052, e-mail: [email protected]. stabilizers of the knee, and injury to it often results in signif- 0003-9993/03/8404-7322$30.00/0 icant disability. Three of the most commonly applied tests to doi:10.1053/apmr.2003.50026 determine an ACL injury are the anterior drawer test, the Arch Phys Med Rehabil Vol 84, April 2003 PHYSICAL EXAMINATION TESTS OF THE KNEE, Malanga 593 Table 1: ACL Tests Test Description Reliability and Validity Tests Comments Anterior The subject is supine, hip Harilainen11 350 acute knees evaluated, with 79 arthroscopically confirmed drawer flexed to 45° and knee Sensitivity: 41% acute ACL injures. Prospective study. test flexed to 90°. Examiner sits Sensitivity (under anesthesia): 86% on the subject’s foot, with Katz and Fingeroth12 Testing performed only with patient under anesthesia. hands behind the proximal Sensitivity: 22.2% (acute injuries) tibia and thumbs on the Sensitivity: 53.8% (chronic injuries) Retrospective study. tibial plateau. Anterior force Specificity: Ͼ97% (acute and chronic) Limited sample size: 9 acute ACL injuries and 12 chronic. applied to the proximal Jonsson et al14 107 patients, all with documented acute or chronic ACL tibia. Hamstring tendons Sensitivity: 33% (acute injuries) ruptures. palpated with index fingers Sensitivity: 95% (chronic injuries) to ensure relaxation. Specificity not assessed because only positive ACL ruptures Increased tibial included. displacement compared Donaldson et al15 Retrospective study. with the opposite side is Sensitivity: 70% (acute injuries) Study not designed to evaluate specificity because authors indicative of an ACL tear. Sensitivity (under anesthesia): 91% reviewed only positive cases. Specificity: not reported Mitsou and Vallianatos16 144 knees, with 60 acute injuries all assessed within 3 days of Sensitivity: 40% (acute injuries) injury. In the group of 80 chronic injuries, the 4 false- Sensitivity: 95.24% (chronic injuries) negative drawer tests were associated with bucket-handle Specificity: not reported tears. Kim and Kim13 Testing performed only with patient under anesthesia. Sensitivity (under anesthesia): 79.6% Specificity. Not reported Retrospective study. Lachman Patient lies supine. Torg et al17 All ACL injuries were chronic. 93 knees with combined tears of test Knee held between full Sensitivity: 95% the ACL and median meniscus. All 5 false negatives were extension an 15° of flexion. Specificity: not reported associated with bucket-handle tears of the meniscus. Donaldson et al15 Retrospective study. Sensitivity: 99% Study not designed to evaluate specificity because authors Femur is stabilized with 1 Specificity: Not reported reviewed only positive cases. hand while firm pressure is Katz and Fingeroth12 Testing performed only with patient under anesthesia. applied to the posterior Sensitivity (under anesthesia): aspect of the proximal tibia 84.67% in an attempt to translate it Specificity (under anesthesia): 95% Retrospective study. anteriorly. Limited sample size: 9 acute ACL injuries and 12 chronic injuries. Test is positive (indicating Kim and Kim13 Testing performed only with patient under anesthesia. ACL rupture) when there is Sensitivity (under anesthesia): 98.6% anterior translation of the Specificity: not reported Retrospective review study. tibia with “soft” endpoint. Mitsou and Vallianatos16 All ACL injuries were chronic. 144 knees, with 60 acute injuries Sensitivity: 80% (acute injuries) all assessed within 3 days of injury. Sensitivity: 98.8% (chronic injuries) Jonsson et al14 107 patients, all with documented acute or chronic ACL Sensitivity: 87% (acute injuries) ruptures. Sensitivity: 94% (chronic injuries) Specificity not assessed because only positive ACL ruptures included.
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